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SAN J O A Q U I N Environmental Health Department <br /> ---COUNTY---- <br /> ' �.}rEc;fnrss yrot; <br /> i <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: j '"_ '�' "�, PR#: <br /> LOCATION: , ° I gPEA "" ' MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit; �?, ����ate of Inspection: <br /> Type of Housing Unit: ❑Single Family Dwelling (O Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: �'� Gas Provided by: y auf <br /> HOUSING UNIT INSPECTION <br /> Interior Checkllst Comments <br /> Unit has hot and cold running water. p kay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. 00kay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). -Okay <br /> Needs Re air• <br /> Doors and windows are accessible/operable to allow for safe exiting, Okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary,No insect/rodent Infestations present, 00kay <br /> All appliances(stove,water heaters,air conditioning units,heaters)are El Needs <br /> 2bkae air* <br /> properly vented strapped and are maintained in a safe,working order. El Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown a0kay <br /> In working order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). DOkay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). 00kay <br /> ❑Needs Repair* <br /> All counters,sinks,tollets,tubs,showers are working and in sanitary condition. 2'Okay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have <br /> El Needs ay air* <br /> no water leaks and are clean and In good condition. l�kay <br /> ❑Needs Repair* <br /> Exterior Checkllst <br /> Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. kay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling palnt,holes,etc. [IOkay <br /> L'Needs Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. jo0kay <br /> ❑Needs Re air* <br /> Propane tank has barrier protection and'No Smoking"signage. okay <br /> ❑Needs Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. I]Okay <br /> ElNeeds Re air•. <br /> The electrical panel is covered and protected from tampering. 20kay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. EOkay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. DOkay <br /> 01 Needs�Re <br /> air* <br /> The sewage system is functioning,with no surfacing wastewater or backup, []Ok <br /> Needs air* <br /> *Needs Repair Pleasespecify date repairs to be com feted.Any Building Permits required for repairs must be obtained and finaled. <br /> 1 certify that I have Inspected the above noted unit and that the Information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> DAA TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />